PT MANOOR BULATN LESTARI

PAYMENT ADVICE
FOR USER DEPARTMENT : Project Cost Centre : No. PA/XI/2022 /_____
Brief Description or purpose of Material / Service: Date: 22/XI/ 2022

Condolences for Inspector of Labor in West Kutai (Darwin H. Siregar, SH)

Name Of Vendor : ANTONIA ELVI

Original Invoice / RA Bill
PO / WO No / Date Value GRN No / Date PR No. / Date No / Date Due Date NFA No. Date

FOR RELEASE OF ADVANCE PAYMENT

FOR RELEASE OF PAYMENT AGAINST INVOICE / BALANCE PAYMENT
ADVANCE AMOUNT REQUESTED
IDR / $ Invoice Value Rp 2,500,000
Justification for advance / Deduction / Addition as under : Less : Recovery / Deduction if any

Less : Advance paid if any

Add : Addition if Any

BANK
CASH
Mode of Payment (Bilyet Giro) AMOUNT PAYABLE ( Before PPh if any) IDR / $ Rp 2,500,000
( In Words ( IDR /$)
BANK DETAILS OF VENDOR / SUPPLIER NPWP No
Name Of Bank Branch Address & City Account No
BNI 1301555319

________________________ _______________________ ___________________ _____________________________ _________________________

Prepared By Verified Certified By HOD Audited-Finanace&Accounts Approved By - COO
Prepared ( Name & Date) Recommended ( Name & Date) Verified ( Name & Date) Appproved ( Name & Date)
NAME & DATE NAME & DATE NAME & DATE
NAME & DATE NAME & DATE

ENCLOSURE
6) Copy Of PO / WO Acknowledged by
1) Original invoice ( Yes / No) vendor 11) Fuel / lubricant - Consumption statement & stock details - ( Yes / No ) Or NA
2) Original Faktur Pajak- If PPN is 7) Signed copy of Note to CEO / GPC 12) Copy of Aktha - If payment to be released in the name of Director/ Partner
charged in invoice ( Yes / No ) ( Yes / No ) ( Yes / No) or NA
8) Quality / Test Report for Fuel ( Yes /
3) Copy Of GRN ( Yes / No ) No ) Or NA 13) Copy of NPWP / KTP - For deduction of PPh ( Yes / No) or NA
9) Weighment Slip No if any ( Yes /
4)Work Completion Cerificate (Yes/No ) No ) Or NA 14) Bank Details Of Vendor Supplier - Copy of Passbook ( Yes / No)
10) Material Rejection Memo
5) RA Bill Control sheet ( Yes / No) ( Yes / No ) Or NA 15) Other Document if any / as per PO/ WO

FOR USE OF FINANCE / ACCOUNTS DEPT

SAP (GL) Code GL Head Dr Cr RECEIVED BY
ACCOUNTS DEPT
Name:
Deduction :
1) PPh @

NET AMUNT PAYABLE - IDR / $ DATE : / /20

( In Words : (IDR/$)
PAYMENT DETAILS
Name Of Payee BG No. / CASH Date Amount Bank&Branch :
Branch :

Prepared By Name & Date Verified By ( Name & Date) Appproved By ( Name & Date) Received By ( Name & Date)
Rev-01/15/6/21